Healthcare Provider Details

I. General information

NPI: 1043133655
Provider Name (Legal Business Name): MYLOAN THI LE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2026
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

563 QUINCY AVE
CLOVIS CA
93619-7664
US

IV. Provider business mailing address

563 QUINCY AVE
CLOVIS CA
93619-7664
US

V. Phone/Fax

Practice location:
  • Phone: 559-930-7721
  • Fax: 559-930-7721
Mailing address:
  • Phone: 559-930-7721
  • Fax: 559-930-7721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number499513
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: